Interview

Hypertension leads to many complications & is associated with many co-morbidities

Prof. Dr. M A Rashid

CEO & Senior Consultant

Ibrahim Cardiac Hospital & Research Institute

Dhaka

As an eminent physician, would you please tell us, in brief, about the overall scenario of Hypertension in Bangladesh?

Hypertension (HTN) is an increasingly important medical and public health problem. In Bangladesh, approximately 20% of adult and 40–65% of elderly people suffer from HTN.

According to Non Communicable Disease risk factors survey, one third of the Bangladeshi population never measured their blood pressure. Among Bangladeshi patients, high incidence of metabolic syndrome, and lifestyle-related factors like obesity, high salt intake, and less physical activity may play important role in the pathophysiology of HTN.

Although awareness against Hypertension has tremendously increased and patients are adhering to healthier and disciplined lifestyle, it is still one of the major causes of death worldwide. What is the reason behind that?

Hypertension is associated with many co-morbidities and is an important component of metabolic syndrome, and also leads to accelerated atherosclerosis leading to stroke and myocardial infarction, eventually death. One of the most important problems with HTN control is the lack of awareness among people about the importance of compliance and adherences to medication. Many patients whose BP is well-controlled on medications, sometimes stop their medicine after a while, because they are unaware of the importance of medication compliance in BP control. Also a number of hypertensive patients have multiple co-morbidities and are taking a lot of medication anyway, it may be another reason for lack of compliance. Although there is a general perception that patients are adhering to healthier lifestyles, this is rather relative. They may be consciously working out, but food habits and work-related stress are all contributors to hypertension, and as such, these factors must also be considered in the overall treatment and control of hypertension.

In Bangladesh, studies have found that non-adherence to antihypertensive treatment was found in 85% of cases; factors determining such non-adherence included lower level of education, low family income, duration of illness, perception related to the disease, lack of accompanying person, and insufficient information from the service provider.

So it’s important that the physician explains these issues clearly to the patients, and stresses on continued medication and regular follow up.

What is the status of Bangladesh compared to the developed countries so far as the prevalence of Hypertension is concerned?

This is difficult to say exactly due to lack of accurate data on prevalence of HTN in Bangladesh. Globally, the overall prevalence of adult hypertension is around 40%. Bangladesh data have found that the prevalence of HTN was found to be within 15-20% among the adult population of Bangladesh. Across the WHO regions, the prevalence of hypertension was highest in the Africa region, around 40%. The lowest prevalence of raised blood pressure was in the WHO Region of the Americas at 35% for both sexes.

We know Hypertension as a ‘silent killer’. What measures can be taken before to prevent this disease?

Hypertension leads to a number of complications and is associated with many co-morbiditites so it’s important to establish good control of hypertension with treatment targets. In those genetically prone to the disease, prevention may not be possible but we can certainly control hypertension, and maintain target BP so that end organ involvement is delayed and deterred. Good lifestyle modification, regular exercise, improved dietary habits and less salt intake are practical measures that can be adopted. Also adhering to medication and regular follow-up is important.

What other complications are associated with Hypertension which may prove fatal?

Hypertension, when uncontrolled can lead to life-threatening complications such as stroke, myocardial infarction, hypertensive retinopathy and papilloedema, acute left ventricular failure and chronic renal failure.

Research on management of Hypertension has always been in progress globally. Where Bangladesh stands so far as the research on Hypertension is concerned? Is Ibrahim Cardiac Hospital & Research Institute working on this?

There are many groups of anti-hypertensive drugs, both traditional and new ones like angiotensin receptor neprilysin inhibitor (ARNI) and the novel calcium channel blocker cilnidipine. In current practice calcium-channel blockers and ACE-inhibitors and ARB’s are the most commonly prescribed antihypertensive drugs; diuretics and beta-blockers are also commonly used. Most of the anti-hypertensive drugs are also produced locally in Bangladesh, some at par with international standards, and are even exported to other countries.

What is the standard of drugs manufactured in Bangladesh for the management of Hypertension?

In Bangladesh, there have been many small scale researches, however, large studies representative of the population as a whole are somewhat lacking.

A recent study using data from the nationally representative 2011 Bangladesh Demographic and Health Survey (BDHS) including a total of 7,839 (3,964 women and 3,875 men) Bangladeshi adults aged 35 years and older are found that the overall prevalence of hypertension was 26.4 %, and the prevalence was higher in women (32.4 %) than men (20.3 %). Studies have also found that the risk of hypertension was significantly associated with older age, sex, education, place of residence, working status, wealth index, BMI, and diabetes.

A study conducted by Ibrahim Cardiac Hospital among 1915 patients with acute coronary syndrome found that HTN was highly prevalence among ACS patients, with 1421 (74.24%) of the patient population reported as hypertensive. This shows that HTN is a significant risk factor among patients with ACS. However, large scale preferably, nation-wide survey, and clinical research studies should be conducted to identify genetic components to HTN, role of hypovitaminosis D, salt intake and also best response to drug therapy including ACE gene polymorphism are needed. The data yielded from such large scale studies would help to formulate a national policy to combat hypertension efficiently and effectively.

Between male and female, who are more prone to this disease? Does it also prevail in children and adolescents?

That is difficult to say as various recent data have yielded different results in terms of gender related prevalence. WHO data have found that men have slightly higher prevalence of HTN than women. But as I mentioned before, one study in Bangladesh did find that HTN prevalence was higher in women (32.4 %) than men (20.3 %).

As for children and adolescents, the exact prevalence of HTN in children in Bangladesh is not known. One study involving 6–16-year-old school children of Dhaka city found a prevalence of 0.55%, but this is probably an underestimate of the true prevalence. The increasing prevalence of childhood obesity and sedentary lifestyle among children could be a contributing factor in addition to genetic components. Especially the altered perception to childhood obesity by the parents in south Asian population, makes the situation even worse .

Lastly what are your suggestions for a patient with Hypertension to lead a normal life?

Good lifestyle habits, regular exercise and dietary control, limited salt intake, and most importantly adherence to medication and being on regular follow up are important. Hypertension is certainly a disease that can be well-controlled and with good control, patients can lead an almost normal life without complications.